So, you know, the Dr. Irani was going to show an edge. They're having some technical issues. So we're going to start an edge here and if his technical issues are resolved, then we'll switch to him. So this is a middle aged gentleman who came in with cholangitis. He has runaway gastric bypass anatomy and he has 1.3 centimeter stone in his duct. We're using a, so the plan is to do edge EOS directed transgastric ERCP. In my practice, this is what I do. I go straight to edge instead of enteroscopy ERCP or lab assisted ERCP. So we can talk why and data, etc. In terms of technique. We, this is the remnant stomach. I think Todd likes to, to describe it as a $10 sign. Yes, I do. Yeah. And we see it as a kind of collapsed. And Todd, can you explain how you make sure this is the excluded stomach? Well, what I do first, first of all, the, the, what you see looks very much like it, but I, I check contrast before I commit to using the lambs to outline the stomach and show that it is indeed the excluded stomach, which has a characteristic sort of banana shape, if you will, as it goes across and then goes back up toward the fundus. So, so that's, and then, so before I commit, I want to outline that it is that there have been some discussion about it not being the excluded stomach. When you see the $10 sign, but I think If you inject and you're in, you can outline the stomach. So please come towards me. I mean, that's critically important to do, even though it looks like a $10 sign, you really want to confirm that it's the remnant stomach, right? So the one thing is here, we're going to make sure this is definitely the stomach. So it looks like is with the, as you can see, it's completely collapsed. You do a test injection live and you can see the contrast is flowing in the stomach off. So I moved my needle. I just want to make sure we're still in place. You don't want to inject intramural. Yeah, I think you have a little bit of an I do, I do. So we're gonna, we're gonna now make sure that's flowing live. Yeah, so we may have to But you can see that the vertical part of the proximal stomach there to the right of your scope, which is what you want to see. So, because, you know, we attach to a pump. Yeah. And, you know, here I'm going to actually pull my needle back because I think part of this was intramural. And of course, we don't want to mess it up. So I'll just go inject somewhere else to make sure we get the lumen. So that's, that's the test injection. You want to get to see the contrast going towards the fundus. And are you using a 19 gauge FNA needle here? Yeah, yeah, yeah. There you go. You're in the space there. So now, so what Todd is saying, it feels it's free. You know, it's a free space. I'm going to inject now live. The other thing you can do is put the Doppler on and you should see swirling if you're in the lumen, whereas if you're in the intramural, you won't see a Doppler signal. Now that looks nice. Yeah. Yeah, I like your description of the banana. Yeah, yeah. Okay, so let's get the pump, see if we can fill the stomach. The other thing is, when you see the sand dollar sign, it really means you're probably in the mid body of the stomach. Hey Samir, hey, you know, if you don't mind, why don't we just meet in the, in the... You're usually in the mid body of the stomach when you see the sand dollar sign. And often when you end up wanting to put the axios is more in that vertical part. Once you get it all filled, that's my experience because the angle going into the stomach is not acute. When you want to get the ERCP scope through, you're not working to get around the corner. You know what I mean? Okay, good. So, so here, just one, one, sorry, you have my back here. So one important thing is our job now is just to fill, doesn't matter where the puncture is. Usually, initially it ends up, the first puncture is in the antrum. So what you want to do before you put the stent, you actually pull the scope back and point it towards the body. Exactly. You don't want to be distal and you don't want to be too proximal because the fundus is a very, very vascular. So the body is perfect. The body was a flora. So now we see, come, come up, please, to show the stomach being filled. We gave him a step. I have to step away one second. I'll be right back. Okay. What 50% diluted contrast and saline or something. Yeah, exactly. A mix of contrast and saline. And we're injecting through a pump through the 19 gauge needle. And we just are filling the stomach here. Once we like it, then we pull the scope back a little bit and fluoroscopically point towards the gastric body and place a 20 millimeter axis. Flora. So here's looking good. I like your point, Mohan, though, about it doesn't matter where you puncture here right now, because you're going to fill the entire stomach up and then you'll decide where the optimal place is for the axios. Yeah, this is just a filling. It really doesn't matter. You see the stomach was collapsed, but very important point is what happened initially. We have a little bit of intramural injection. You can still see it there. So this is why the test injection, you don't want to put the pump right away. That's the injection. Make sure the contrast is pulling back into the fundus. You know, it's in the lumen. That's, that's, that's key for a shot. Okay. So that's probably good. So let's take this needle out. And how much is it? Is it about like three, 500 CCs that you're putting in? Yeah, this was, this was about that 300 CCs. So now I'm going to let's do it under fluoroscopy live. So pull back here a little bit and here. So you see what happened here? They'll do indented with the scope, fluoroscopically, and you know, you're very close and nice. Okay. 20 millimeter. And can you comment Mohan on 15 versus 20? Do you always go for 20? Yeah. If you, so Dr. Irani, who was supposed to show his case, him and I have collected data on this. And we actually, if he was doing it, he will be doing the same way. And I think Todd also does it like we do it. We always use the 20 millimeter and always suture and always do the case same session. And the migration rate using this method is very, very low. Never zero, but close to that. But you got to use a 20 and you got a suture. So to follow up on that, there's an audience question here, Mohan, if a 20 is not available and only 15 LAMs is available, would you proceed with ERCP in the same session or later? So we've done it before. There's going to be a lot of friction. Um, you know, so I, I prefer not to. So you see here, we were using the cottery tip. We went through the stomach and I pushed the catheter all the way. So this is 20 millimeter, how to access. So can we zoom in the camera guys and show the room view? Zoom towards me, please. Like that was the device. Let me know if you guys have the view. The room view? Not yet. Okay. So, okay, good. Good. Okay. So this is, so you see the catheter is all the way down. We want to lock the catheter, open the stent deployment catheter and deploy. You as well. Yeah. So, but put the EOS and the room view, please, side to side. Because we want to see that distal phalange you just deployed. Okay. So, uh, good. So now I am going to pull back. So basically I want to oppose the excluded stomach to the pouch. So I'm pulling, pulls gently and slowly until we have little tension on the catheter like that. And it looks like a football. Yeah. And then I'm going to deploy the second phalange in the scope. And when maintaining the EOS view, you see there. So now, so this is the intra channel release. So now we have to push the catheter outside the scope. Please switch to end of view to show it. We have enough coming out. Yup. Good. So, so here a little bit, pull away and talk to the right. And you're seeing it there. So now I'm going to push it out of the scope and that's it. So now we're going to pull out right away and then I'm going to dilate to 18 millimeter. So we'll get a, just a CRE and dilate to 18. So you can dilate to 20, but you know, sometimes occasionally we've seen bleeding, especially if you're high up in the fundus. And the stent we use to tampon out the bleeding is through the scope, a esophageal stent. And the one we have is 18 millimeter. So I don't, so to have a good tamponade, I go maximum to 18 in case we have severe arterial bleed. So that's why I do 18 and not one. And I think that was a great demonstration of deploying the proximal phalange moen totally in the scope and then pulling back, right. Straightening out and turning to the right. Very important to make sure it's deployed properly. So this is now a CRE fluoro shot, please. Good. So let's show also, let's show, good. They have, you have the fluoro image. We're going to go to right away to 18. Fluoro on the side, live. Now, Moen, for people who don't suture or don't have access to suturing. Yeah. You know, you've got to fix the stent. Right. If you have a stent fixed device, I think it's okay. Right. Is it 18? Down. Yeah. So, you know, the 20, it is a 20 millimeter compared to 15, it's increased in 72% in the surface area. So it's significant, but there can be some friction, you know, so to avoid that friction and migration, then, then, you know, it's not worth the risk. You've got to suture because this is how you avoid problems. Remember, if you have stent migration, that's a perforation. So here, we're going to take a look. You see guys, the end of view, we have the stomach. So what we're going to do now is I'm going to remove the EOS scope. I'm going to put the double channel with the suture mounted on it, suture quickly, and then we'll do the ERCP. So if you want to go to another room and come back, we'll show you a little bit of suturing. Okay, good. So we so that's the 20 millimeter axis. It's already dilated. We put the first suture, I'm finishing it. Go ahead. I like to put two sutures just to reinforce it well, but it takes a few minutes and then we'll be ready for the ERCP. So Muin, if you don't have the suture system or you don't suture, can you talk about what do you think the risk is with one stage? I might've been out of the room when you discussed this. Yeah, but we kind of alluded to this, but it's so important. You know, for me, the rule is to do a single stage edge, I have to use a 20 millimeter axis and I have to anchor it because this is where we eliminated basically the migration and perforation. So if we don't suture, I still worry about risk. The third thing is during the procedure, you can encounter, like you place the stent at a tough angle and if your scope is not going well, you have a lot of friction, you got to pause, you know? So, and you know, I've had instances where I had to use an alternative scope. You know, maybe the Pentax scope is a little bit more flexible than the Olympus scope. So occasionally we've switched. We're lucky to have both. Right. Let me just say what, I don't suture them. I've lately, when I've gone more proximally in the stomach, like you did, I've not encountered a migration, but I always have a salvage strategy prepared. So what I do is go through, do the ERCP and leave the ERCP guide wire in the duodenum, gently withdraw. And if it looks like there's a dislodgement, I immediately place a TTS fully covered stent to bridge a six centimeter by a 20 millimeter fully covered stent right through there. And they tend to do fine. Yes. You know, Todd, we, we've had these instances where we have to put the stent and I used to do the same thing, leave a wire behind while coming back, just with this plan, you know, this literally took five minutes to suture. No, no, I understand. But not everybody, not everybody sutures. Yeah. And the other way to do it is a stent fix. I mean, also this is all costly, right? You have a cost to it. Yeah. Yeah. But, but I would, I would, uh, uh, err on, uh, just avoiding a perforation and need for a stent, and at the end, sorry, just one more, one more point. You know, if, if you are, if you don't suture, you can't anchor the stent, you don't have a 20 millimeter device. Most, again, most of the cases are elective. You don't have to push it and do it the same session. You know, this patient has a 1.3 centimeter stone and he came with cholangitis. Oh, yeah. Yeah. So this one, we have to go for it. So now the first step is access and stent placement and dilation that's done. Two is anchoring that's done. Now we go to step three, which is the ERCP same session. That's a very important point, Moen, right? If it's an elective procedure, which most of the times it is, and as you said, if you don't have access to suturing, 20 millimeter stent, fix it, et cetera, et cetera. I think it's important not to try to rush it and do it all in one session for the sake of the patient and wait and then bring them back. Yeah. So if you want to think about it, the patient has to come back anyways, in a few weeks to remove the stent. So single session is really not saving a procedure because you can say, Hey, you know what? Let me bring you back in two weeks or three weeks. Track is formed. I do the ERCP and then you take the access out in the same session. So if you think about it that way, as long as it's an elective procedure. The other thing you can do, although I've gotten away from this and gone more to single stage edge is you could do an hepatical gastrostomy and temporize, but yes, it's additional. And then you can work to integrate. If they're not huge stones like what you're dealing with here, often you can balloon dilate and integrate, push the stone down in a room-wide patient. But I agree with you, it's a case like this, you want to go trans-papillary. Can I ask one real quick question? Let's put the end of you while you're, okay. So here's the end of you. And we're going to, so the way we can elate this, or we go through the stent is as if it's a pylorus. So you want to aim to the top of it, like here. And then we go, we go here, we didn't go in. So here we have to be careful because it looks like there's an angle there. And, but here we are able to pass. Guidance for us can be helpful in this situation. Yep. Because if you feel this is moving with you, then, then you got to stop. So, so one thing here that I've seen, I don't know, Todd, if you've experienced this, is the, flora, please. So here you see, we're going in the wrong direction, our flora. Yeah. Yeah. So live. Okay, good. So is the pylorus, you know, you know, I find that the pylorus is stenotic in some of these patients and we've had to dilate or change scopes. Maybe it's a access point or angle issue. I think it's a combination. I agree with you because you are coming completely different in your approach. It's almost like, as if you've experienced, as you know, doing intraoperative ERCP with a surgical laparoscopic port into the excluded stomach, things are different, right? Than they are when you go through the mouth. And I think it more sometimes resembles that. And the same can be said when you get to the papilla, your view is often a little bit different than what you're used to in a native situation in terms of positioning. You know what I mean? Yeah. And here I'm, I'm experiencing this kind of feel, you know, I, yeah, it's, it's not going smoothly. It's not friction. Right. Flora, please. It's, you feel resistance as you're pushing. What about putting the patients on the left lateral decubitus? Yeah. I mean, the change position is next and you know, this patient is a row and wide gasket bypass patient. So he is really barely fitting on the table and very, very hard to maneuver. But yes, that's, if I can, then I'll change the patient's position. And that's usually the next trick, Ali, is left lateral. So we'll, we'll continue to try here to get there. So if, if you guys have somewhere else to go, please do and come back. There's an audience question real quick. There's an audience person, a question that's asking if you don't have suturing, can you use clips to fix the stent? Yeah. Through the scope clips are, will be like placebo, you know, just for you, just anchoring it to the mucosa. So it'll make you feel better, but it's really, it will not do anything. Exactly. Yeah. Agree. Last real quick question, or we can come back to this. How do you, one of the things I think to avoid the bad persistent fistula, I know you're going to talk about closure, is also not avoiding going through the staple line with your axios. Would you agree with that? You know, we, we, we looked at that and, and it's really, it didn't, so logically, yes, because that's a relatively ischemic area. So healing may be less, but it didn't pan out. You know, the most important factor is you take the axios out as soon as you don't need it. And my limit, starting at four weeks, you know, three weeks may be safe for the fistula to form, but I like four weeks. So here, I think guys, I have to move the patient like Ali mentioned to a left lateral. So if you want to go somewhere else to another room and then I guess they want us to stay here for a minute. And I think we can. Final point. Final point. So sometimes. Let's see if we can move the patient left lateral. Yep. Go ahead. Yeah. We know, final point that sometimes you can anticipate the problem putting from the beginning, the patients on the left lateral. Is that possible for doing the US procedure? Yeah. So for, yes, for the flora, this is what's happened now. It's actually in, not, not uncommon Ali. So yeah, maybe it's a good idea just for the fluoroscopy part. Initially it's much easier to just interpret the, the images. Maybe you guys, we can get some help to turn the patient to the left side. Okay. I'm sweating a little bit here. If you guys. Ah, we can't tell. No, I mean, we work hard for this. So a fluoro shot I'll update you in a minute. Okay. They've been wiping, they've been wiping your brows. So here's what we did. We couldn't really go left lateral. He's more than 400, 450 pounds can barely fit on the table. But we changed scope into a little bit more flexible scope, very difficult position. I don't know if you, if I don't think you can see the scope, but I have an alpha loop on the ERCP scope. So here you go. So, so position is extremely difficult. Yeah, we see. Yeah. And the fluoroscopy image is not the best because as you can imagine with with all the fat layer. So let's inject, please put the balloon up. So we're going to get an occlusion cholangiogram live, please. Okay. We, the wire is in the bubble, I believe. So we're gonna see if we can get it to the bile duct and given the difficulty with the positioning and everything else, the fact that he has cholangitis, he's been on the virus for a few days. So I feel comfortable injecting at this time. Bring back the wire, please. And okay. Yeah. The stone is distal. And here we haven't really opacified the proximal duct. Maybe the, maybe the cystic insertion is very low. Yeah. Live. Yeah. If you could. Here we go. Here we go. Yeah. Off, just inject, inject, inject. So my goal here, so by the way, he has antiphospholipid syndrome. He came in with like iron out of five. We can't, he has to go on anticoagulation right away. So it's going to be a sphincteroplasty type of thing. Fluoroshot. Okay. Let's put a wire up now, put a stent and come out. So we're going to decompress him. Let this, let the track heal and then come back for a more elective ERCP with the, with the sphincteroplasty possible EHR. Fluoroshot. Okay. Push the wire up, please. Live. So it's still going. Yep. Come back. Come back. Up. Come back. So let's see. And here you see, I can't show you the papilla well, just because of the position here. Live. Okay. Go now. Yep. Go. Go. Go. Off. Okay. Balloon down. So we're going to put a 10-7, please. Exchange. So what do you guys think of now just establishing drainage in a patient with phalangitis rather than try to go and do a lot? Yeah, I agree with that. I mean, just like you said earlier, you got to come back later anyway, to take the stent out. And the most important thing for everybody to remember is that drainage is the most important thing. And so especially if the patient's unstable, which I know he isn't, but it's better to just sometimes drain and come back to fight another day. It looked like the distal duct as it entered was kind of narrowed down there. I'm thinking that's all stone there. This is remember a 1.3 centimeter stone. Right. So I think that whole, so, so which comes to, this is what I meant to ask to Todd, Linda and Ali, if Ali is still awake. Yeah, I'm here. Good. So the, this guy, I can't cut, I can't do a sphincterotomy. And the stone is look how distal that thing is. How are we going to perform sphincteroplasty or large balloon sphincteroplasty? Well, today, if you're only getting in there to decompress. No, next time, next time. Well, I know people make a big, a big deal about dilating next to a stone and the risk of dilating alongside a stone. I personally, I've done it. And maybe I've just been lucky. I've not had something bad happen dilating next to a stone. Now you might say, well, then I don't have to, maybe I shouldn't dilate quite as much because then you have the added diameter of the stone that's non-compressible. So you might want to go a little less on your balloon perhaps. But I, I think that's where you're headed with this, right? Is it safe? You know, sometimes you actually can fragment the stone with the dilating balloon next to it, but that'd be interesting. Can I make a point, Todd? Yes, please. As long as the bile duct is nicely dilated like it is today, I don't feel major issues in making dilation even though some stones are in between the balloon and the dilation. I want to go back to an earlier point that we mentioned. So the fact that you can postpone on the RCP. So the problem I see with doing two procedures in this patient is a very challenging position. It's very challenging the RCP. So just in case in this specific situation, you can try to resolve the entire situation with a single procedure probably can be a little bit better because it is a special patient, very difficult to manage, very difficult to move around the table and changing the position and getting access to the papilla. So Wayne, would you consider to do this in a just one shot? Yeah, I will say 90% of the times we're going to finish the job right away. Here, you know, I, because of the alpha loop, for me, I'm going to do a EHL on this guy. So I got to have a better scope position on this. I will say with the, if I put the spyglass, I'm going to be falling back every five seconds. So for me, manipulating the scope, getting everything in, you know, it's better to let that track form and do this on a more elective basis. And, you know, I always also just think about, you know, you spend a lot of time and there is a fatigue factor. So respect that, drain the patient, this guy has cholangitis. I'm not going to do EHL and inject a lot of fluid in a patient with cholangitis. Right. I totally agree. I mean, I think it's, you got drainage now with that stent, so he's good, you know, and you can bring him back on another day. So now we're going to pull this, so fluoroscopy, please, back to the stomach, the proximal stomach, just to show you how to pull the scope back. Okay. First shot. Okay. So, so Linda, just one point here, while pulling this scope back, you know, I'm unlocking my wheels, making sure the scope is straight so that we don't hook on the, on the stent and pull back. And this is the last point is when we pull back, we have to check on this, make sure it's still on the luminal side. And if it's not, you pull it and put a stent maybe across, but this, what I'm doing now, looking at it, you feel good about it. You feel safe. This patient is going to do well. So what I want to do is bring him back in four weeks for EHL. And if we're done with the job, I'll pull the axis at the same time. And I think the other thing is that with the stent in there, it may start to break down the stone a little bit as well over the next four weeks. So that may be of some help as well. So any specific post-procedure recommendation after this kind of approach? Yeah, no, no, we, you know, the, because this is a one-step procedure, like with the luminal opposing stent, you can give just one dose of antibiotics and you're done, you know, because there's no leakage, you know, you're not putting a wire and exchanging catheters, there's no intra-procedural leakage. So just one dose of antibiotics. Can you discharge the patient the same day? Yeah. So this patient obviously is different, he's already an inpatient, but we do this as an out, on an outpatient basis for sure. Any final questions from the audience or from the moderators? Yeah, can you guys hear me? Great work. Cheyenne, any final comments on this procedure before we switch to IU? One last comment is the other reason to do this as a one-stage is, and it's a small reason, is if you get everything done the first time, in case you have post ERCP bleeding, you still have access to go back in and address it. Now, if you do all your work at the time of removing that LAMS and you get post ERCP bleeding three or four days later, then you have to re-access that point and that's a challenge. So that's another justification of trying to do it in one stage, which is why I think we... I know they close quickly. I don't know if they close within 72 hours, which is when most people are going to bleed, but I hear you, some people delay bleed seven or 10 days later, which time it's probably closed, but maybe it's 72 hours, it would still be accessible, but your point is well taken. Yeah, perfect. Thank you guys for the excellent comments and moderation and expertise.

cholangitis

1.3 centimeter stone

endoscopic retrograde cholangiopancreatography

axis stent

suturing

dilation

post-procedure recommendations